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Accident Reporting, Accident Reporting, Investigation and AnalysisInvestigation and Analysis

‘ ‘ Those who cannot remember the past Those who cannot remember the past are condemned to repeat it’are condemned to repeat it’

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis Presentation ContentsPresentation Contents

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Types of incident(as %) reported to HSA(>3days lost) 2002

32.2

19.46.35.3

5.3

4.6

3.9

3

2.4

2.1

2

1.5

0.4

0.4

0.3

0.1

10.9

Injured while handling, li fting or carrying

Slips, trips or falls on same level

Injured by hand tools

Injured by falling objects

Fall from height

Contact with moving machinery parts

Injured by a person – malicious

Transport (excluding road traffic accidents)

Exposure/ contact with harmful substance

Road traffic accidents

Injured by a person – non-malicious

Struck by something collapsing/ overturning

Contact with electricity

Injured by an animal

Fire or explosion

Drowning or asphyxiation

Miscellaneous or not otherwise classified

IntroductionIntroduction

Why report and investigate Why report and investigate accidents? accidents?

‘‘PREVENT A RECURRENCE OF THE SAME ACCIDENTPREVENT A RECURRENCE OF THE SAME ACCIDENT’’

It is worth doing it well!It is worth doing it well!

Learn from what went wrongLearn from what went wrong Determine the causesDetermine the causes Prevent recurrencePrevent recurrence Improve the work environmentImprove the work environment Meet regulatory requirementsMeet regulatory requirements Cost of incidentsCost of incidents Moral ObligationMoral Obligation Define trendsDefine trends Provision of information in case of litigationProvision of information in case of litigation Reduction of operating costs by control of Reduction of operating costs by control of

accidental lossesaccidental losses Expression of concern by managementExpression of concern by management

IntroductionIntroduction

Incident DefinitionsIncident Definitions ACCIDENTACCIDENT - an undesired event that results in personal - an undesired event that results in personal

injury or property damage.injury or property damage. INCIDENTINCIDENT - an unplanned, undesired event that adversely - an unplanned, undesired event that adversely

affects completion of a task.affects completion of a task. NEAR MISSNEAR MISS - incidents where no property was damaged and - incidents where no property was damaged and

no personal injury sustained, but where, given a slight shift no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have in time or position, damage and/or injury easily could have occurred.occurred.

Lost Time AccidentLost Time Accident – an accident resulting in time off work – an accident resulting in time off work Dangerous OccurrenceDangerous Occurrence - escape of flammable substance, explosion, - escape of flammable substance, explosion,

fire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel fire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel ruptures, transport incidents, bursting of reveolving wheel, O/H electric line ruptures, transport incidents, bursting of reveolving wheel, O/H electric line contact, building collapsecontact, building collapse((1993 Safety Health & Welfare at Work( General 1993 Safety Health & Welfare at Work( General Application )Regulations Application )Regulations ))

Reportable IncidentReportable Incident – – injured cannot return to work within 3 days of injured cannot return to work within 3 days of incident(1993 Safety Health & Welfare at Work( General Application )Regulations incident(1993 Safety Health & Welfare at Work( General Application )Regulations Form to be submitted to HSA( downloadable at Form to be submitted to HSA( downloadable at www.hsa.iewww.hsa.ie ) )

IntroductionIntroduction

Incident Classification for ReportingIncident Classification for Reporting Near Miss Incident:Near Miss Incident: a near miss incident where there is no loss be it injury or a near miss incident where there is no loss be it injury or

property damage however it could have resulted in personal harm/damage property damage however it could have resulted in personal harm/damage under slightly different circumstances, such incidents are reported to the under slightly different circumstances, such incidents are reported to the Supervisor and formally logged on a Near Miss Report.Supervisor and formally logged on a Near Miss Report.

Level 1 - Minor Incident:Level 1 - Minor Incident: a level one incident can typically be dealt with by a level one incident can typically be dealt with by the person identifying the problem. The supervisor should be informed and the the person identifying the problem. The supervisor should be informed and the incident formally logged on an Incident Report; this will permit assessment of incident formally logged on an Incident Report; this will permit assessment of the incident particularly with regard to the possibility of re-occurrence and the the incident particularly with regard to the possibility of re-occurrence and the potential for a more serious event. Examples:potential for a more serious event. Examples: minor localised fire, minor minor localised fire, minor first aid injury(less than one day off work)first aid injury(less than one day off work)

Level 2 - Serious Incident:Level 2 - Serious Incident: immediate action should be taken where possible immediate action should be taken where possible by the person identifying the incident. The supervisor should be immediately by the person identifying the incident. The supervisor should be immediately informed and should assess the situation. Thereafter, the supervisor will contact informed and should assess the situation. Thereafter, the supervisor will contact the necessary emergency services and officials as per the emergency plan. the necessary emergency services and officials as per the emergency plan. Examples: injury (person is likely to be out of work for more than one day but Examples: injury (person is likely to be out of work for more than one day but less than three days), containable fire, containable environmental damageless than three days), containable fire, containable environmental damage..

Level 3 - Severe Incident:Level 3 - Severe Incident: immediate action should be taken where possible immediate action should be taken where possible by the person identifying the incident. The supervisor should be immediately by the person identifying the incident. The supervisor should be immediately informed and should assess the situation. The supervisor will contact the informed and should assess the situation. The supervisor will contact the necessary emergency services and necessary necessary emergency services and necessary personnelpersonnel as per the site as per the site emergency plan. Examples:persons trapped, serious fire, threat to the safety of emergency plan. Examples:persons trapped, serious fire, threat to the safety of personnel, serious environmental damage, serious injury( person likely to be personnel, serious environmental damage, serious injury( person likely to be out of work > 3days)out of work > 3days), fatality, fatality. .

Level of Incident and Investigation involvedLevel of Incident and Investigation involvedRISKRISK Level 1Level 1

LowLowLevel 2Level 2

ModerateModerate

Level 3 Level 3

HighHigh

Injury Severity Injury Severity First Aid Medical Aid

(<1 day off work) 

  Medical Aid(1<days off<3)

Fatality Lost Time Accident

(>3 days) Serious Incident

Reportable to HSA Disabling injury

Damage Damage SeveritySeverity

Up to E30,000 Up to E100,000 Over E200,000

Production LossProduction Loss Less than 3 hoursLess than 3 hours 3 hours to one day3 hours to one day 1 day or more1 day or more

Customer Customer ImpactImpact

Product requires work to meet customer standards

Product will not meet customer standards

Loss of CustomerMajor customer dissatisfaction

Personnel Personnel involved in involved in

investigationinvestigation

* Front line supervisor* Worker(s) /Witnesses

involved * Area Safety Representative

* Front line Supervisor* Worker(s) /Witnesses

involved* Area Safety Representative

* Safety Manager

* Front line supervisor

* Worker(s)/Witnesses involved

* Area Safety Representative

* Head of Department* Safety Manager

Investigation Investigation Report Report

ResponsibilityResponsibility

Supervisor - Within the same shift

Supervisor - Immediately after

personnel and area are safe

Supervisor -Immediately after

personnel and area are safe

Responsibility Responsibility for Remedial for Remedial

Actions Actions

Head of Department Head of Department Head of Department

Accident or

Incident Occurs

Initial response Supervisor actions as per emergency plan

Medical AidPrevent secondary accidentsNotify emergency services

Safety ManagerContact insurance

Contact hsa if required

Is the Incident Level 1?First Aid Medical Aid (<1 day off work)Damage < E30,000Production Loss < 3 hoursProduct requires work to meet customer standards

Is the Incident Level 2?Medical Aid(1<days off<3)E30,000<Damage<E200,0001 day >Production Loss > 3 hoursProduct will not meet customer standards

Is the Incident Level 3?FatalitySerious Injury - Lost Time(>3 days)Serious Incident Reportable to HSADamage>E200,000Production Loss < 1 dayLoss of Customer or major customer dissatisfaction

Accident Team Investigates

Front line supervisorWorker(s)/Witnesses involved Area Safety Representative

Accident Team Investigates

Front line supervisorWorker(s) /Witnesses involved Area Safety RepresentativeSafety Manager

Accident Team InvestigatesFront line supervisorWorker(s) /Witnesses involved Area Safety RepresentativeSafety ManagerHead of Department

Incident ReportSupervisor Responsible for completion and forward to Safety Manager within 24 Hours

Management Actions

Head of Departmenttrack remedial actionsSafety Manageradd to incident databaseInclude in incident analysis

Collect more evidence and

re-analyse

Does analyses show what happened, what should have happened and

why?

Collect EvidenceInterview witnessesPhotographsSketches, survey, site mapsRelative positionsExamine equipment & machineryFailed partsExamine MaterialsExamine records

AnalyseResponse and loss limiting actionsImmediate causes (Substandard acts and conditions)Basic causes (personal & job factors)Program management (standards and compliance)

Analyse causes

Develop Remedial Actions inc. timescales and

responsibilities

Management Actions

Managing Directorreview at next management meetingHead of Departmenttrack remedial actionsSafety ManagerIssue incident informationadd to incident databaseReview at next safety committee meetingInclude in incident analysis

Report findings and actions

No

YesYes Yes

Yes

No

No

Incident Investigation FlowchartIncident Investigation Flowchart

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction

Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

IntroductionIntroduction

Reporting IncidentsReporting Incidents Employee must report to SupervisorEmployee must report to Supervisor

Supervisor responsible for initiating reporting procedureSupervisor responsible for initiating reporting procedure

Supervisor responsible for complete of incident report for Supervisor responsible for complete of incident report for near-miss, Level 1 and Level 2 incidents involves Safety near-miss, Level 1 and Level 2 incidents involves Safety Manager and Area Safety RepresentativeManager and Area Safety Representative

Supervisor in conjunction with relevant Head of Supervisor in conjunction with relevant Head of Department responsible for completion of Level 3 Department responsible for completion of Level 3 incident reports and also involves Safety Manager and incident reports and also involves Safety Manager and Area Safety RepresentativeArea Safety Representative

Head of Department responsible for completion of Head of Department responsible for completion of corrective actionscorrective actions

Reports to Senior Manager and Safety ManagerReports to Senior Manager and Safety Manager

Initial ResponseInitial Response

Typical ProcedureTypical ProcedureAll incidents must be reported immediately by the All incidents must be reported immediately by the

employee concerned to their Supervisor:employee concerned to their Supervisor:

If aIf a Near MissNear Miss incident the Supervisor shall ensure a Near Miss Report incident the Supervisor shall ensure a Near Miss Report is completed immediatelyis completed immediately..

If aIf a Level 1Level 1 incident the Supervisor in conjunction with the area Safety incident the Supervisor in conjunction with the area Safety Representative completes the Incident Report Form and forwards to Representative completes the Incident Report Form and forwards to Safety Manager within 24 hours.Safety Manager within 24 hours.

If a If a Level 2Level 2 incident immediately after attending to any victim and incident immediately after attending to any victim and minimisation of property damage the Supervisor ensures the accident minimisation of property damage the Supervisor ensures the accident scene is secured, prevents access by unauthorised persons and calls the scene is secured, prevents access by unauthorised persons and calls the Safety Safety ManagerManager and the area Safety Representative who will assist the and the area Safety Representative who will assist the Supervisor in completing the Incident Report FormSupervisor in completing the Incident Report Form, taking witness , taking witness statements statements and and completion of the completion of the investigationinvestigation..

If aIf a Level 3Level 3 incident the Supervisor immediately after attending to any incident the Supervisor immediately after attending to any victim and minimisation of property damage ensures the accident scene victim and minimisation of property damage ensures the accident scene is secured, prevents access by unauthorised persons and calls the is secured, prevents access by unauthorised persons and calls the Safety Safety ManagerManager, the area Safety Representative and the relevant Head , the area Safety Representative and the relevant Head of Departmentof Department, , who will assist the Supervisor in completing the Incident who will assist the Supervisor in completing the Incident Report FormReport Form, taking witness statements , taking witness statements and and completion of the completion of the investigationinvestigation..

Initial Response Initial Response

The Supervisor The Supervisor

Takes control of the sceneTakes control of the scene Calls first aid and emergency Calls first aid and emergency

servicesservices Controls secondary incidentsControls secondary incidents Identifies sources of evidenceIdentifies sources of evidence Preserves evidence from alteration Preserves evidence from alteration

or removalor removal Determines the loss potentialDetermines the loss potential Notifies appropriate managementNotifies appropriate management

Discuss you company’s emergency response Discuss you company’s emergency response procedures in the event of fire, injury, procedures in the event of fire, injury,

chemical spillchemical spill

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response

Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Incident Investigation and AnalysisIncident Investigation and Analysis Tips for investigation and analysisTips for investigation and analysis

Encourage a no-blame reporting culture Encourage a no-blame reporting culture Focus must be to improve working conditions and methodsFocus must be to improve working conditions and methods Approach with an open and objective mindApproach with an open and objective mind All facts learnt corrective action takenAll facts learnt corrective action taken Fact finding not fault findingFact finding not fault finding An opportunity for employees and management to work together An opportunity for employees and management to work together

to correct an unacceptable situationto correct an unacceptable situation An incident will happen again if underlying causes are not An incident will happen again if underlying causes are not

correctedcorrected Delve deep to establish underlying causes do not accept all Delve deep to establish underlying causes do not accept all

answers given at face valueanswers given at face value Be prepared to look beyong the injured person, his co-workers, Be prepared to look beyong the injured person, his co-workers,

supervisor, managersupervisor, manager Consider communication skills and language barriersConsider communication skills and language barriers Get as much factual information as possible to get the complete Get as much factual information as possible to get the complete

picturepicture

Incident InvestigationIncident Investigation Effective Incident InvestigationEffective Incident Investigation

Establish the facts:Establish the facts:

Who? What? When? Where? The size?Who? What? When? Where? The size? Analyse the facts isolating contributary factors:Analyse the facts isolating contributary factors:

Who or what was involvedWho or what was involved What hazards were present?What hazards were present? What controls failed?What controls failed?

Identify actions to prevent a recurrenceIdentify actions to prevent a recurrence Implement the corrective actionsImplement the corrective actions

Incident InvestigationIncident InvestigationWho should lead investigation?Who should lead investigation?The Supervisor(The Supervisor(of those involvedof those involved), why?), why?

They have a personal interestThey have a personal interest They know the people and conditionsThey know the people and conditions They know how best and where to get the They know how best and where to get the

information neededinformation needed They will initiate or take any remedial actionThey will initiate or take any remedial action They benefit from investigatingThey benefit from investigating

Where there is major loss or loss potential or Where there is major loss or loss potential or where multiple supervisors are involved it is where multiple supervisors are involved it is

beneficial that the investigation also beneficial that the investigation also involves the Head of Department for the involves the Head of Department for the

area. In all cases it is recommended that the area. In all cases it is recommended that the Supervisor involves the safety professional Supervisor involves the safety professional on his/her site to assist in the investigationon his/her site to assist in the investigation

Incident InvestigationIncident Investigation Collecting evidence and informationCollecting evidence and information

Record: Record: Pre-accident conditions, Accident sequence,Pre-accident conditions, Accident sequence,

Post-accident conditionsPost-accident conditions

Position evidencePosition evidence – people(witnesses), equipment, materials & – people(witnesses), equipment, materials & environment, use sketches maps, photos, videoenvironment, use sketches maps, photos, video(Consider plant line up, valve alignment, tools labels, signs)(Consider plant line up, valve alignment, tools labels, signs)

People evidencePeople evidence – statements from all involved and witnesses, – statements from all involved and witnesses, interview separatelyinterview separately

Parts evidenceParts evidence – machinery, tools and other equipment that – machinery, tools and other equipment that could have contributed to the incidentcould have contributed to the incident

Paper evidencePaper evidence – all relevant records such as training records, – all relevant records such as training records, equipment records( maintenance, servicing), MSDS, equipment records( maintenance, servicing), MSDS, procedures, codes of practice, pre-start checklists, permits, procedures, codes of practice, pre-start checklists, permits, area rules, standardsarea rules, standards

Consider reconstructing incident from above informationConsider reconstructing incident from above information

Initial ResponseInitial ResponseTypical ProcedureTypical Procedure

Photographs of the scene are taken If there is a possibility that the accident could become a fatality the If there is a possibility that the accident could become a fatality the

scene must remain undisturbed until viewed by HSA Inspector and scene must remain undisturbed until viewed by HSA Inspector and Gardai where required.Gardai where required.

Arrange for survey plans of the site to be prepared. These are to Arrange for survey plans of the site to be prepared. These are to include the following :include the following :

Locality Plan & details of accident site;Locality Plan & details of accident site; Detailed plan of view showing details after the accident and include such things Detailed plan of view showing details after the accident and include such things

as: Equipment used in rescue operations; Position of materials, ladders, as: Equipment used in rescue operations; Position of materials, ladders, equipment, etc. involved in the accident; Position from where photographs were equipment, etc. involved in the accident; Position from where photographs were taken; Position of persons involved in the accident; and other relevant taken; Position of persons involved in the accident; and other relevant information.information.

A sectional view (if necessary). Any sections made are to be marked on the A sectional view (if necessary). Any sections made are to be marked on the detailed plan.detailed plan.

Take evidence from witnesses at the scene and make note of any Take evidence from witnesses at the scene and make note of any piece of evidence.piece of evidence.

Check relevant equipment, maintenance and training recordsCheck relevant equipment, maintenance and training records Analyse condition of equipment materials with specalist input Analyse condition of equipment materials with specalist input

where necessarywhere necessary Prepare a report detailing the circumstances of the accident within Prepare a report detailing the circumstances of the accident within

24 hours and submit to the Safety Manager24 hours and submit to the Safety Manager.. The report will include The report will include the Incident Report Form the Incident Report Form and witness incident analysis forms and witness incident analysis forms which which provides for systematically identifying immediate causes, basic provides for systematically identifying immediate causes, basic causes and lack of control.causes and lack of control.

In the event of a Level In the event of a Level 2 or Level 2 or Level 3 incident, immediately following the incident the 3 incident, immediately following the incident the Supervisor Supervisor shall ensure the following:shall ensure the following:

Incident InvestigationIncident Investigation Accident PhotographyAccident Photography

Photograph the scene from all sidesPhotograph the scene from all sides

Use long, medium, close-up sequenceUse long, medium, close-up sequence

Accompany with good notes and sketchesAccompany with good notes and sketches

Identify by number, time, date & name of Identify by number, time, date & name of photographerphotographer

Incident InvestigationIncident Investigation Interviewing WitnessesInterviewing Witnesses

Calm, objective, impartial, open mind, search for facts not opinionsCalm, objective, impartial, open mind, search for facts not opinions Do not interrogate/cross examineDo not interrogate/cross examine As soon as As soon as possible( theorising increases as memory decreases)possible( theorising increases as memory decreases) Interview separately and privately, use a tape recorder only with witness Interview separately and privately, use a tape recorder only with witness

permissionpermission If significant conflict follow up interviews may be necessaryIf significant conflict follow up interviews may be necessary Assure them the information is being used for accident prevention not to Assure them the information is being used for accident prevention not to

apportion blame apportion blame Get the individuals versionGet the individuals version Use open questions (cannot be answered with a simple yes or no)Use open questions (cannot be answered with a simple yes or no) Do not express an opinion or argueDo not express an opinion or argue Record critical information quicklyRecord critical information quickly If not at the site of the accident use visual aids, sketches etc.If not at the site of the accident use visual aids, sketches etc. End on a positive note and keep the line open End on a positive note and keep the line open Review completed statement with witness and have it signed Review completed statement with witness and have it signed

Helpful Interview QuestionsHelpful Interview Questions

What were you doing? Where were you working? How were you injured? How do you think the accident occurred? What is the safety procedure for the job?

How were you trained for the job? Have you fully described the circumstances of the accident as you know them?

Take a look at the Witness Incident Analysis form recommended for Level 2/3 incidents

Incident InvestigationIncident Investigation Parts ExaminationParts Examination

Parts – machinery, tools and other equipment that could have contributed to the incident

Proper item for taskProper item for task Damage - type, extent, patternDamage - type, extent, pattern Previous damage – defects, misusePrevious damage – defects, misuse WearWear Safeguards – machine guards, emergency cut-Safeguards – machine guards, emergency cut-

offsoffs Labels, signs, markingsLabels, signs, markings

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation

Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Incident analysisIncident analysisWhat’s involved?What’s involved?

Determine what happened –immediate cause –Determine what happened –immediate cause –unsafe practices/conditions unsafe practices/conditions ( ask the question would the ( ask the question would the accidnet have happened if this particular factor was not present?)accidnet have happened if this particular factor was not present?)

Determine why it happened basic causes –Determine why it happened basic causes –personal/job factorspersonal/job factors

Cover deficiencies in the management systemCover deficiencies in the management systemWOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?

Determine appropriate remedial action based Determine appropriate remedial action based on the immediate and basic causeson the immediate and basic causes

Apportion responsibility to implement Apportion responsibility to implement corrective actionscorrective actions

Report findings to senior managementReport findings to senior management Follow-up and monitor corrective actionsFollow-up and monitor corrective actions

Incident AnalysisIncident Analysis

THE DOMINO SEQUENCE

How Accidents Happen

The domino described below is a model that will help you see how accidents happen.

Lack of Control Basic Cause

Immediate Cause Accident Loss

OrganizationalFailure to:- Plan Direct Organize Control

Lack Of:TrainingResourcesBelief

Unsafe Act Unsafe Condition

Undesired, Unplanned Event Which Disrupts Work Activity

Death Injury Property damage Lost Time Lost Productivity

Incident AnalysisIncident Analysis

Lack of Control Organisational failure means that the organisation, at one or more levels, did not effectively/properly plan, direct, organize, control or

combination thereof, its resources

Resources are: Time, Tools, Equipment, Materials, Manpower

Failure to PLAN means: All aspects of the job, task or operation were not planned effectively so that an unexpected accident was not eliminated.

Failure to DIRECT means: Personnel involved in the job, task or operation were not instructed and trained as to the potential hazards involved and means to eliminate or control those hazards.

Failure to ORGANIZE means: All resources that were needed to do the job safely were not present, proper, and/or in safe

operating condition.

Failure to CONTROL means: Failure to ensure that the job or task was actually conducted as planned, organized and directed.

Incident AnalysisIncident Analysis

Basic CausePersonal and job factors - lead a person to commit an unsafe condition or act

Job factor - Lack of Training/ Lack of Resources

No training at allTraining that was incomplete or inadequate or not understoodTraining that was not repeated frequently enoughResources (time, tools, equipment, materials, manpower) necessary

to do the job safely are not providedResources not proper (skills, size, abilities, type)Resources not in safe operating conditionInadequate supervisionInadequate work standards, procedures, work practices, maintenance

Personal factor - Lack of Belief There is a belief that a negative consequence will not result because of their action. Lack of belief is almost always caused by past experience. Factors that can contribute to it are:

Poor morale/low motivation/stress Peer pressure Productivity pressures Inadequate resourcesInadequate capability

Incident Analysis

Immediate Cause

Immediate causes are the unsafe acts and/or conditions that lead directly to the accident.

Unsafe acts account for 85% of accidents; unsafe conditions account for 14% of accidents.

However, 85% of the unsafe conditions were caused by an unsafe act.

Therefore, we can say that 97% of all accidents are caused directly or indirectly by an unsafe act.

Incident Analysis

Accident

An accident is:

“An unplanned, undesirable event which disrupts work activity”

An accident always results in a loss.

Incident Analysis

Loss

The loss is the result of an accident. (Disruption of work activity).

Approximately 30 different losses have been identified as potential results of accidents, for example:

Death Lost ProductivityInjury Civil PenaltiesLost Time Replacement CostsDamaged Morale Economic LossDamaged Tools Loss of Client GoodwillDamaged Equipment Lost CompetitivenessLost Materials

Human Element of Accident Human Element of Accident CausationCausation

Latent Failures Active & LatentActive FailuresLatent FailuresLatent Failures

Fallible Decisions

Training & SkillsWork Atmosphere

Line Management Deficiencies

PlanningSupervision

PsychologicalPrecursors

of Unsafe ActsCommunication

Job FactorTeam Work

Unsafe ActsCommunicationPerson Factor

Inadequate Defences

Tools & Equipment

Organisational Process

Local Working Conditions Active Failures Defences

Senior Management

Line Management

FrontlineSupervisor

OperatorsMaintenance

Crews

Safety Equipment

Casual SequenceCasual Sequence

Human Elements of Accident Causation (Reason 1990)

Incident analysisIncident analysisLoss Causation ModelLoss Causation Model

Lack of Control

Inadequate

•Systems

•Standards

•Compliance

Basic Causes

Personal Factors

Job/system factors

Immediate Causes

Substandard Acts/practices

Substandard

Conditions

Incident

Event

Contact with energy or surface

Loss

Unintended harm or damage

•People

•Property

•Processes

In an incident analysis situation use this model and write down the loss, incident event, immediate, basic causes and relevant lack of controls under each heading in list form as per the Incident Report Form

This makes it possible to identify the causes and relevant corrective actions to prevent a reoccurrence.

Problem Solving ModelProblem Solving Model

Incident Form: Immediate Incident Form: Immediate CausesCauses

Immediate CausesImmediate Causes (What sub standard actions & Conditions caused the event)::

Tick all applicable below and explain here:

SUBSTANDARD ACTIONS Operating equipment without Operating equipment without authorityauthority Failure to warnFailure to warn Failure to secureFailure to secure Operating at improper speedOperating at improper speed Making safety devices inoperableMaking safety devices inoperable Removing safety devicesRemoving safety devices Using defective equipmentUsing defective equipment Using equipment improperlyUsing equipment improperly Failure to use PPE properlyFailure to use PPE properly Improper loadingImproper loading Improper placementImproper placement Improper liftingImproper lifting Improper position for taskImproper position for task Servicing equipment in operationServicing equipment in operation HorseplayHorseplay Under influence of alcohol or drugsUnder influence of alcohol or drugs Working in dangerous situationWorking in dangerous situation Non-adherence to rules/standardsNon-adherence to rules/standards

SUBSTANDARD CONDITIONSSUBSTANDARD CONDITIONS Inadequate guards or barriersInadequate guards or barriers Inadequate or improper protective Inadequate or improper protective equipmentequipment Defective tools equipment or Defective tools equipment or materialsmaterials Congested or restricted actionCongested or restricted action Inadequate warning systemInadequate warning system Fire and explosion hazardFire and explosion hazard Poor housekeeping disorderPoor housekeeping disorder Hazardous environmental Hazardous environmental conditions(gas, dust etc.)conditions(gas, dust etc.) Noise exposuresNoise exposures Radiation exposureRadiation exposure High or low temperature exposuresHigh or low temperature exposures Inadequate or excess illuminationInadequate or excess illuminationInadequate ventilationInadequate ventilation Defective PPE

Incident Form: Basic CausesIncident Form: Basic CausesBasic CausesBasic Causes (What personal factors & job

factors caused the event)::Tick all applicable below and explain here:

Personal factorsPersonal factors Inadequate capabilityInadequate capabilityLack of knowledge Lack of skillLack of skill StressStress Improper motivationImproper motivation

Job FactorsJob Factors Inadequate LeadershipInadequate Leadership Inadequate engineeringInadequate engineering Inadequate purchasingInadequate purchasing Inadequate maintenanceInadequate maintenance Inadequate tools & Inadequate tools & equipmentequipment Inadequate work Inadequate work standardsstandards Wear & TearWear & Tear Abuse or misuseAbuse or misuse

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis

Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Incident analysisIncident analysis Remedial ActionsRemedial Actions

Temporary ActionsTemporary Actions – correct – correct substandard actions and conditionssubstandard actions and conditions

Permanent ActionsPermanent Actions – remedy personal – remedy personal factors and job factorsfactors and job factors

Remedial ActionsRemedial Actions must be must be:: Communicated clearlyCommunicated clearly Responsible person identified and timescale Responsible person identified and timescale

established for their completionestablished for their completion Follow-up conducted by Investigation TeamFollow-up conducted by Investigation Team Department Manager responsible to ensure Department Manager responsible to ensure

completioncompletion

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions

Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Incident ReportIncident ReportTypical ContentsTypical Contents

Title, date and timeTitle, date and time Location of the accidentLocation of the accident Type of injury or damage/who and what was involvedType of injury or damage/who and what was involved Cost of lossesCost of losses Description of what happened including emergency Description of what happened including emergency

response sequence response sequence How the accident occurred/extent of damageHow the accident occurred/extent of damage Immediate(direct(energy sources, haz. materials etc.) & Immediate(direct(energy sources, haz. materials etc.) &

indirect causes(unsafe acts and conditions) & basic indirect causes(unsafe acts and conditions) & basic causes causes

(personal/environmental factors)(personal/environmental factors) Lack of control(management policies)Lack of control(management policies) Remedial actions temporary & permanentRemedial actions temporary & permanent Management reviewManagement review OtherOtherNote:Note: Timeliness of report is critical, best reports are written promptlyTimeliness of report is critical, best reports are written promptly Accident reports are usually ‘discoverable’ this means they can be Accident reports are usually ‘discoverable’ this means they can be

used by parties to an action for damages or criminal chargesused by parties to an action for damages or criminal charges

Incident ReportIncident Report

Where to?Where to?

Incident reports forwarded to the Safety Manager are Incident reports forwarded to the Safety Manager are processed as follows :processed as follows :

All incident reports are analysed and the summary All incident reports are analysed and the summary information is presented at the next monthly information is presented at the next monthly management meetingmanagement meeting and safety committee meeting and safety committee meeting

All Level 2 and Level 3 incidents are reviewed at the All Level 2 and Level 3 incidents are reviewed at the next weekly management meetingnext weekly management meeting. . Any lessons Any lessons learned are communicated to management and learned are communicated to management and employees employees from ifrom information distributed to all nformation distributed to all Supervisors(for inclusion in tool box talk ) and Supervisors(for inclusion in tool box talk ) and on on Company Notice BoardCompany Notice Boardss

Incident reports are copied to the relevant Head of Incident reports are copied to the relevant Head of Department and General Manager in the case of Department and General Manager in the case of Level 2 and Level 3 incidentsLevel 2 and Level 3 incidents

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report

Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Near Miss ReportingNear Miss Reporting

Reporting of Near Miss Incidents is criticalReporting of Near Miss Incidents is critical

Near misses provide a much larger base for more effective control of accidental lossNear misses provide a much larger base for more effective control of accidental loss Eliminate the causes of near misses, reduce the potential for more serious Eliminate the causes of near misses, reduce the potential for more serious

accidents, this is the basis of any proactive safety management systemaccidents, this is the basis of any proactive safety management system High potential incidents should be analysed thoroughlyHigh potential incidents should be analysed thoroughly

1Serious or Major Injury

10Minor Injuries

30Property Damage

600Incidents with no visible

injury or damage

Near miss

Accident Ratio Study

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting

Cost of incidentsCost of incidents Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Analysis of costsAnalysis of costsConsider the following:Consider the following:

Cost of dealing with incident( such as first aid, Cost of dealing with incident( such as first aid, emergency supplies, staff downtime)emergency supplies, staff downtime)

Costs of incident investigation( such as staff time, Costs of incident investigation( such as staff time, consultants time)consultants time)

Cost of getting back to business( such as re-Cost of getting back to business( such as re-scheduling, clean-up, hire of equipment)scheduling, clean-up, hire of equipment)

Business Costs( such as cost of injured persons Business Costs( such as cost of injured persons salary, replacement salary, lost orders)salary, replacement salary, lost orders)

UK HSE useful incident cost calculator template – UK HSE useful incident cost calculator template – next slidenext slide

©Consultnet Ltd©Consultnet Ltd

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents

Incident StatisticsIncident Statistics Summary of ResponsibilitiesSummary of Responsibilities

Accident Statistics Accident Statistics AnalysisAnalysis

Accident data base should be establishedAccident data base should be established Identify trends and focus systems where they can Identify trends and focus systems where they can

produce the greatest return on invested time and produce the greatest return on invested time and energyenergy

Accident analysis statistics should be:Accident analysis statistics should be: produced regularly by the Safety Departmentproduced regularly by the Safety Department reviewed at regular management and safety committee reviewed at regular management and safety committee

meetingsmeetings summary available to all employeessummary available to all employees Identify repetitive or signifcant itemsIdentify repetitive or signifcant items

Accident Statistics AnalysisAccident Statistics Analysis

Statistics may include:Statistics may include: Number of near-miss, property damage, first aid, medical aid, lost time incidents, Number of near-miss, property damage, first aid, medical aid, lost time incidents,

fire, environmental eventsfire, environmental events Lost time injury frequency rates and severity ratesLost time injury frequency rates and severity rates

Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000

Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000

CostsCosts Cause and control analysisCause and control analysis

Type of accidents by department, work section, occupationType of accidents by department, work section, occupation

Equipment/substances involvedEquipment/substances involvedActivity at time of injuryActivity at time of injuryAge of person/length of serviceAge of person/length of serviceTime of dayTime of dayImmediate causes(substandard acts and conditions)Immediate causes(substandard acts and conditions)Basic causes( Personal and job factors)Basic causes( Personal and job factors)Lack of control(inadequate programme standards or compliance with standards)Lack of control(inadequate programme standards or compliance with standards)Remedial action completion by departmentRemedial action completion by department

Problem solving project teams to address critical problems identifiedProblem solving project teams to address critical problems identified

Accident Reporting, Investigation and Accident Reporting, Investigation and

AnalysisAnalysis

IntroductionIntroduction Incident ResponseIncident Response Incident InvestigationIncident Investigation Incident AnalysisIncident Analysis Remedial ActionsRemedial Actions Incident ReportIncident Report Near Miss ReportingNear Miss Reporting Cost of incidentsCost of incidents Incident StatisticsIncident Statistics

Summary of ResponsibilitiesSummary of Responsibilities

IncidentsIncidents

Summary of ResponsibilitiesSummary of Responsibilities

All Employees must report all incidents to their SupervisorAll Employees must report all incidents to their Supervisor All Supervisors responsible for initiaiting accident investigationsAll Supervisors responsible for initiaiting accident investigations All Heads of Department are responsible for taking appropriate action on the All Heads of Department are responsible for taking appropriate action on the

conclusions and results of any incident investigation within their Department.conclusions and results of any incident investigation within their Department. All Heads of Departments are responsible to ensure that the supervisors in their All Heads of Departments are responsible to ensure that the supervisors in their

department are fully aware of, understand and initiate the Incident Reporting department are fully aware of, understand and initiate the Incident Reporting and Investigation Policy and attend and Investigation Policy and attend relevant relevant training.training.

The Safety Manager will be responsible for The Safety Manager will be responsible for providing technical support to the providing technical support to the Supervisor in the course of the incident investigation, issuing incident Supervisor in the course of the incident investigation, issuing incident information for communication to all employees, producinginformation for communication to all employees, producing the incident statistics the incident statistics and presentation to monthly management and presentation to monthly management and safety committee and safety committee meetingmeeting

The Safety Manager will ensure that management, employees and their The Safety Manager will ensure that management, employees and their representatives are adequately consulted and informed on the incident representatives are adequately consulted and informed on the incident investigation policy and provision of training as regards implementation of the investigation policy and provision of training as regards implementation of the policypolicy

In the event that a Level 2 or Level 3 incident meets the requirement of In the event that a Level 2 or Level 3 incident meets the requirement of reporting to the Health & Safety Authority, the Safety Manager contacts the reporting to the Health & Safety Authority, the Safety Manager contacts the relevant Inspector, submits the completed statutory report form and co-relevant Inspector, submits the completed statutory report form and co-ordinates any subsequent investigation with the Inspector.ordinates any subsequent investigation with the Inspector.

The Safety Manager is responsible for reporting Level 2 & 3 incidents to the The Safety Manager is responsible for reporting Level 2 & 3 incidents to the Company Loss Adjuster and Company Insurance Co-ordinator and co-ordinating Company Loss Adjuster and Company Insurance Co-ordinator and co-ordinating any subsequent follow-up investigation.any subsequent follow-up investigation.

Accident or

Incident Occurs

Initial response Supervisor actions as per emergency plan

Medical AidPrevent secondary accidentsNotify emergency services

Safety ManagerContact insurance

Contact hsa if required

Is the Incident Level 1?First Aid Medical Aid (<1 day off work)Damage < E30,000Production Loss < 3 hoursProduct requires work to meet customer standards

Is the Incident Level 2?Medical Aid(1<days off<3)E30,000<Damage<E200,0001 day >Production Loss > 3 hoursProduct will not meet customer standards

Is the Incident Level 3?FatalitySerious Injury - Lost Time(>3 days)Serious Incident Reportable to HSADamage>E200,000Production Loss < 1 dayLoss of Customer or major customer dissatisfaction

Accident Team Investigates

Front line supervisorWorker(s)/Witnesses involved Area Safety Representative

Accident Team Investigates

Front line supervisorWorker(s) /Witnesses involved Area Safety RepresentativeSafety Manager

Accident Team InvestigatesFront line supervisorWorker(s) /Witnesses involved Area Safety RepresentativeSafety ManagerHead of Department

Incident ReportSupervisor Responsible for completion and forward to Safety Manager within 24 Hours

Management Actions

Head of Departmenttrack remedial actionsSafety Manageradd to incident databaseInclude in incident analysis

Collect more evidence and

re-analyse

Does analyses show what happened, what should have happened and

why?

Collect EvidenceInterview witnessesPhotographsSketches, survey, site mapsRelative positionsExamine equipment & machineryFailed partsExamine MaterialsExamine records

AnalyseResponse and loss limiting actionsImmediate causes (Substandard acts and conditions)Basic causes (personal & job factors)Program management (standards and compliance)

Analyse causes

Develop Remedial Actions inc. timescales and

responsibilities

Management Actions

Managing Directorreview at next management meetingHead of Departmenttrack remedial actionsSafety ManagerIssue incident informationadd to incident databaseReview at next safety committee meetingInclude in incident analysis

Report findings and actions

No

YesYes Yes

Yes

No

No

Incident Investigation FlowchartIncident Investigation Flowchart

Accident InvestigationAccident Investigation Case StudyCase Study

Form teams for the investigating and Form teams for the investigating and reportingreporting

Analyse the factsAnalyse the facts Identify the immediate and basic causesIdentify the immediate and basic causes Recommend remedial actionsRecommend remedial actions Complete Incident ReportComplete Incident Report Present findingsPresent findings

Remember Rudyard Kipling'sRemember Rudyard Kipling's

I keep six honest serving men,I keep six honest serving men,They taught me all I knew,They taught me all I knew,

Their names are What and Why and How Their names are What and Why and How and Where and When and Whoand Where and When and Who

Accident Reporting, Accident Reporting, Investigation and AnalysisInvestigation and Analysis

ConclusionConclusion

WHEN AN ORGANIZATION REACTS SWIFTLY WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS REAFFIRM ITS COMMITMENT TO ITS ACTIONS REAFFIRM ITS COMMITMENT TO

THE SAFETY AND WELL-BEING OF ITS THE SAFETY AND WELL-BEING OF ITS EMPLOYEESEMPLOYEES

Accident Reporting & Accident Reporting & InvestigationInvestigation

Further informationFurther information(click to follow link):(click to follow link): Irish HSA Irish HSA Accident NotificationAccident Notification information and information and accident statisticsaccident statistics UK IChemE comprehensive information source on major UK IChemE comprehensive information source on major incidentsincidents UK HSE Report on UK HSE Report on Accident InvestigationAccident Investigation UK guidance on use of UK guidance on use of digital images as evidencedigital images as evidence EU research on EU research on work related accidentswork related accidents US site on US site on injury research and controlinjury research and control The The Investigation ProcessInvestigation Process Research Library Research Library US based US based OSHA accident investigationOSHA accident investigation information, information, safety payssafety pays software and software and fatal factsfatal facts

informationinformation CHEMSAFETY.govCHEMSAFETY.gov is the US Chemical Safety and Hazard Investigation Board's site, it is the US Chemical Safety and Hazard Investigation Board's site, it

investigates major chemical accidentsinvestigates major chemical accidents US based US based OSHA Studies of Occupational FatalitiesOSHA Studies of Occupational Fatalities. Links to OSHA reports of . Links to OSHA reports of

fatality/catastrophe investigations fatality/catastrophe investigations United States United States Chemical Safety & Hazard InvestigationChemical Safety & Hazard Investigation Board Board

Australian guidance on Australian guidance on learning from accidentslearning from accidents Canadian based information on Canadian based information on reporting and investigating accidentsreporting and investigating accidents New Zealand information on Aftermath - New Zealand information on Aftermath -

The Social and Economic Consequences of Workplace Injury and IllnessThe Social and Economic Consequences of Workplace Injury and Illness Investigation Process Investigation Process Research LibraryResearch Library